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- The study
- Source of Funding
- Ethical Approval
The ebb and flow of leadership skill development for nurses, in New Zealand and internationally, has been influenced by a plethora of health sector reforms. The consequences for nursing in relation to reform and restructuring processes have been profound: significant reductions in registered nursing full-time equivalent positions, decreased job satisfaction levels, increased turnover rates, fragmentation of health care team relationships as well as negative effects on nurses physical and psychological well-being (Aiken et al. 2001, Cummings 2006, Oulton 2006, Carvalho & Santiago 2009). Policy changes resulting in negative outcomes for nursing and other health care staff have also been related to adverse patient outcomes, especially those evidenced via nursing sensitive indicators, such as urinary tract and surgical wound infections and pulmonary failure (Carryer et al. 2010).
One aspect of the reform process has been the introduction of managerial ideology, a market-based approach encouraging competitiveness and commodification of health care service delivery (Carvalho & Santiago 2009). In New Zealand, this ideological approach originally resulted in the decimation of clinical leadership roles in favour of non-clinical managers (Hornblow 1997, Gauld 2000, Fougere 2001, Sage et al. 2001) and, at its zenith, nursing budgets were lost to non-clinical managers, and senior nurse positions were replaced with new graduates (McCloskey & Diers 2005). While it could be argued that the pace of health sector reform in New Zealand has decelerated, changes are ongoing. Regionalization of core services plus the increasing use of Health Care Assistants in the acute and aged care settings are some examples of these. Nurse leadership roles such as Directors of Nursing have now been re-established, as have nurse-manager positions. However, the ability to control the nursing budget remains, to a large extent, outside the parameters of these roles (Carryer et al. 2010). Leadership, according to Redman (2006, p. 296), remains crucial to the future of nursing and the provision of quality patient care. Nurses need to be strategically involved in the planning, development, education and implementation of leadership competencies and skills (Redman 2006, McCallin et al. 2009), and these need to account for the present environment, not the past.
Twentieth-century leadership theories and models were based around a top-down authoritarian and bureaucratic approach which aimed to achieve maximum gains from economies and social systems predicated on industrial production (Uhl-Bien et al. 2007, Hanson & Ford 2010), and as such needed workers who were task-based. However, 21st century economic and social systems emphasize knowledge. Health care is an example of a knowledge-based industry. It is an environment replete with complex processes and networks as well as bureaucratic and hierarchical structures. In order to meet the demands and pressures inherent within such structures, leadership theories and models need to enable and support adaptability, learning, problem-solving, collaboration, innovation and change (Uhl-Bien et al. 2007, Hanson & Ford 2010).
Research investigating leadership skills required by nurses working within these knowledge-based environments reveal a range of pragmatic and metaphysical qualities. For example, nurses working within clinical settings not only need to be patient focused, they also need to be critical thinkers, clinically competent and confident using evidence-based practice, be able to initiate and manage change, as well as understand how the wider financial, political and social landscape impacts upon and influences health policy and direction (Cook 2001a, Davidson et al. 2006, Bretschneider et al. 2010, Casey et al. 2010). Other leadership skills detailed include goal setting and providing colleagues with motivation and support (Davidson et al. 2006). Stanley's (2008) views are more metaphysical in origin and he argues that attributes which are ‘values-base’ or ‘congruent’ are important when considering leadership characteristics. These include an approachable and open manner, role modelling values and beliefs, effective communication skills, decision-making ability and visibility. Advocacy is also considered a necessary component of clinical leadership in order to ensure optimal patient care (Sorensen et al. 2008). Authentic leadership is another values-based model. It incorporates ‘soft skills’, which requires leaders to ‘understand their own purpose, practice solid values, lead with heart, establish enduring relationships, and practice self-discipline’ (George 2003 cited in Shirey 2006, p. 260). Shirey points to a lack of empirical evidence surrounding this leadership model but argues that in the wake of recent behaviours seen in corporate and banking sectors, a leadership style incorporating ‘soft skills’ appears to have merit for organisations as a whole, as well as ‘at the front line or the point of care’ (Shirey 2006, p. 266). The soft skills and values-based approaches have synergy with Practice Development (PD) ideologies, which are described below, and form the basis of the leadership programme outlined in this study. It is also argued nurses require opportunities to learn about and practice leadership because up until recently scant recognition has been given to leadership being considered an intrinsic part of nursing's ‘skill-set’ (Johnson et al. 2010).
While there are numerous postgraduate courses pertaining to developing leadership and management skills, some specific to nursing and midwives and others more generic, within one New Zealand District Health Board (DHB), it was noted these programmes targeted people already in management or leadership positions. After extensive engagement with staff, Nurse Coordinators Practice Development (NCPDs) working with nurses and midwives throughout acute care and community-based settings became aware of a gap in relation to the career development of nurses who showed leadership potential. In light of this discovery, the NCPDs created a programme in 2007 called Pebbles, which aimed to support these nurses. In the initial phase, Pebbles was described as an ‘enrichment’ experience where a cohort of nurses and midwives were exposed to a variety of ideas and skill sets to develop their self-belief and self-efficacy. Raising levels of confidence as well as consciousness about the wider health environment were goals of the programme. As Pebbles continued, by 2009, the raison d'être of the programme altered to specifically focus on leadership development. This paper details an evaluation of the programme carried out in 2010, focusing on the analysis of participants' written comments and interview/focus group data.